F0609

E

Failure to Immediately Report Allegations of Abuse to Facility Abuse Coordinator

Norwalk, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report allegations of abuse to the Administrator (the facility’s abuse coordinator) as required by policy. For one resident with intact cognition and medical conditions including HTN, PVD, and hypothyroidism, documentation on a change of condition/SBAR form dated 3/2/2026 showed the resident reported that a CNA was rough, grabbed her wrist, and twisted her arm, prompting the resident to try to kick the CNA to get away. In an interview, the resident, via translation by the same CNA, stated that on 3/1/2026 she was in bed when the CNA came in, grabbed her left arm tightly, and pressed her fingers into the resident’s left ankle hard, but the resident did not initially report this to anyone.

CNA 1 stated that on 3/1/2026 she went to the resident’s room to change an adult brief, rolled the resident from left to right, and the resident became upset and accused her of grabbing the resident’s left arm and abusing her. CNA 1 reported this accusation to LVN 3, and CNA 2 corroborated that she was present when CNA 1 reported the allegation of abuse to LVN 3. LVN 3 stated that CNA 1 told her the resident had called her a derogatory name and was being aggressive, and that she relayed this to an RN and was instructed to change the CNA’s assignment. LVN 3 further stated that on 3/2/2026 the resident told her that the CNA had twisted her left arm on 3/1/2026, and that she reported this allegation to the Administrator on 3/2/2026, meaning the Administrator was not informed immediately when the initial allegation was made on 3/1/2026.

A second deficiency involved another resident with severe cognitive impairment, aphasia following a cerebral infarction, and total dependence on staff for ADLs. A change of condition/SBAR form dated 3/5/2026 documented that during an IDT meeting, the resident’s family member reported that an LVN had lifted the resident’s sheet, touched the resident’s diaper, then replaced the sheet and left the room during the night shift. The family member stated she had been in the darkened room when the LVN entered, put a hand under the sheet, bent over and whispered something to the resident, and that later the resident communicated via letter board that a nurse had touched him inappropriately and identified the LVN when asked. The family member reported this allegation to an LVN, who said he would report it to an RN. RN 1 stated that the family member told her she did not want the LVN caring for the resident and later reported that the LVN had touched the resident’s private area inappropriately; RN 1 attempted to call the DON the next day but did not reach her and did not report the allegation to the DON. The Administrator stated he was not notified of this abuse allegation until the following day during an IDT meeting, and also confirmed he did not learn of the first resident’s allegation from 3/1/2026 until 3/2/2026, despite facility policy requiring immediate reporting of suspected abuse to the Administrator and other officials.